Demographic changes related to aging necessitate that clinicians have the resources to address eating and swallowing difficulties present in older adults. The capacity to effectively and safely eat or swallow is one of the most basic human needs and also can be a great pleasure. Therefore the loss of this capacity can have far-reaching implications. Many would argue that swallowing is one of the cardinal behaviors needed to sustain life. The process of swallowing requires orchestration of a complex series of psychological, sensory, and motor behaviors that are both voluntary and involuntary. Dysphagia refers to difficulty swallowing that may include oropharyngeal or esophageal problems. More specifically, there may be difficulty in oral preparation for swallowing and/or moving material from the mouth to the esophagus and from the esophagus to the stomach.
Although age-related changes place older adults at risk for dysphagia, an older adult's swallow is not inherently impaired. Presbyphagia refers to characteristic changes in the mechanism of swallowing of otherwise healthy older adults. Clinicians need to be able to distinguish among dysphagia, presbyphagia, and other related diagnoses such as globus hystericus to avoid overdiagnosis and overtreatment of dysphagia. Older adults can be more vulnerable and, with additional stressors such as acute illness and certain medications, they can cross over from having a healthy older swallow (presbyphagia) to experiencing dysphagia. This chapter reviews the normal swallowing process and presbyphagia, as a healthy aging evolution, dysphagia outcomes, multidisciplinary approaches to diagnosing and managing dysphagia, and newly recognized rehabilitation strategies for dysphagia care.
Dysphagia prevalence depends on the specific population sampled, with community-dwelling and more independent individuals having rates near 15%. Upward of 40% of people living in institutional settings such as assisted-living and nursing homes are dysphagic. With the projected growth in the number of individuals living in nursing homes, there is a compelling need to address dysphagia not only in ambulatory and acute care settings but also in long-term care settings.
The consequences of dysphagia vary from social isolation because of the embarrassment associated with choking or coughing at mealtime to physical discomfort (e.g., food sticking in the chest) to potentially life-threatening conditions. The more ominous sequelae include dehydration, malnutrition, and both overt and silent aspiration precipitating pulmonary complications. For the purposes of this chapter, aspiration is defined as the entry of material into the airway below the level of the true vocal folds. Silent aspiration refers to the circumstance in which a bolus comprising saliva, food, liquid, medication, or any foreign material enters the airway below the vocal folds without triggering overt symptoms such as coughing or throat clearing. Both overt and silent aspiration may lead to pneumonitis, pneumonia, exacerbation of chronic lung disease, or even asphyxiation and death. To gain a better understanding of the effect, these consequences have on older adults and the impact of dysphagia interventions, research in this area has aimed to develop more meaningful outcome measures. Assessments focused ...